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Pink coloration at the incision site is a normal finding during healing and not a sign of infection.

A temperature of 37.2°C (99°F) is within the normal range and does not indicate infection.

Crusting along the incision line is a normal part of wound healing and not necessarily an indication of infection.

Chilling the lavage fluid is not recommended because cold solutions can cause hypothermia and worsen coagulopathy.

The client should be positioned on the left side with the head elevated to minimize the risk of aspiration, not on the right side.

A large-bore (not small-bore) NG tube is required to effectively instill and remove lavage fluid and clots.

Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension, so it would not cause hypertension as an adverse effect.

Hyperactivity is not associated with losartan therapy.

Double vision is not a typical adverse effect of losartan.

The scopolamine patch should be applied behind the ear, not on the upper arm.

A dislodged patch should not be reapplied to the same location; a new patch should be placed behind the opposite ear if needed.

Scopolamine patches should be stored at room temperature, not in the refrigerator.

It is appropriate and expected for a guardian to accompany the child to radiology; this is not a warning sign of maltreatment.

A fall from a swing is a plausible cause of injury and not, by itself, a red flag for maltreatment.

Crying loudly when the arm is moved is expected behavior in a child with a fracture and does not indicate maltreatment.

Repositioning the NG tube addresses placement issues, not dehydration from hyperosmolar feedings.

Increasing the rate of formula delivery would worsen dehydration by overwhelming the body with more solute load.

Switching to a lactose-free formula is appropriate for clients with lactose intolerance, not hyperosmolar dehydration.

Seeing dark spots in vision is not an expected outcome after cataract removal; the client should expect improved vision.

Bruising of the eyelids is not a typical finding following cataract surgery.

Cataract removal is usually performed with local anesthesia and sedation, not general anesthesia.

Room numbers are not reliable identifiers because they can change and do not confirm the client’s identity.

A driver license number is not typically used in healthcare settings for client identification.

Place of birth is not a standard or reliable identifier for safe medication administration.

A blood glucose of 150 mg/dL in a child with type 1 diabetes mellitus is within the target range and not urgent.

A 2-year-old with diarrhea and abdominal pain requires monitoring but is not the highest priority compared to airway compromise.

A heart rate of 120/min in a 3-year-old is within the expected range (80–130/min) and not urgent.

The fetal heart rate should be monitored continuously or frequently, not just twice daily, due to the risk of fetal compromise.

A low-protein diet is not appropriate; clients with preeclampsia should maintain adequate protein intake to support maternal and fetal health.

Bed rest or limited activity is recommended to reduce blood pressure and uteroplacental stress, not frequent ambulation.